BUT THEY MAKE US RICH
Two days after interviewing Robert Spitzer in Princeton, it was time to make my way to Washington, DC. With each mile I traveled southward, the temperature seemed to rise a corresponding notch on the thermometer. Being in Washington was uncomfortably reminiscent of parboiling in the steam room of my local gym, so I spent my first morning in a local coffee shop, writing, reading, dealing with e-mails, while periodically asking the perspiring staff to please, please turn the air conditioner up.
Once eleven o’clock struck, I puffed my way along Pennsylvania Avenue, so tightly wrapped up in a jacket and tie that I nearly missed the United States Capitol rising up before me like an ancient seventh wonder. That was my cue to turn right down Second Avenue, past the Library of Congress, the Supreme Court, and toward my destination: Hart Senate Building.
The Hart Senate Building is famous for at least four reasons. It’s a Senate office building (number one). It’s the largest Senate office building (number two). It’s where Barack Obama’s office was located before he was upgraded (number three). The final reason is hinted at by a wall of JFK-like security booths confronting you as you enter. The building had been on high alert ever since an envelope full of anthrax was posted to Senator Tom Daschle’s mailbox in 2001. The whole place had been closed for an entire month while they decontaminated every inch of the place with powerful chlorine gas (number four).
Once I passed through security, I still had twenty minutes remaining before my interview. So I made my way to the vast central indoor courtyard, whose glass-topped atrium vaults an impressive ninety feet into the air, flooding natural light into the corridors and offices below. While sitting there it became clear to me: It was hopeless to pretend I fitted in. My suit was too shabby, my hair too long, and I didn’t have a BlackBerry. Senators and their aides were gliding everywhere, literally dripping with technology, with suits so well-tailored and hair so neatly cropped that they looked as slick and polished as the shiny marble floors. What on earth was I, therefore, doing at the US Senate?
Simply put, I was there to find out more about a malady afflicting most of medicine today, but especially psychiatry. It relates to the fact that pharmaceutical companies are paying physicians for a variety of different reasons, and not all these payments are transparent. The issue is so important because although many years ago psychiatrists did not have extensive financial links with the pharmaceutical industry, in the last twenty years the industry has become a major financial sponsor of psychiatry both in Britain and the United States, having unprecedented influence over psychiatric practice and research.
The facts are telling: Many heads of psychiatry departments now receive departmental income from drug companies, while at the same time receiving personal income.117 Also, nearly all research into psychiatric drugs—antidepressants, neuroleptics, tranquilizers—is now pharmaceutically financed (e.g., nearly 90 percent of all clinical trials in the UK are conducted or commissioned by the industry118). Furthermore, most consultants and academic drug researchers now also receive research funding, consultancy fees, and honoraria from the industry—a fact graphically illustrated by how many members of the DSM-IV and DSM-5 committees have strong financial ties to the drug industry.
A recent study from the University of Massachusetts, for example, worryingly showed that of the 170 panel members of DSM-IV, a full ninety-five members (56 percent) had one or more financial associations with the pharmaceutical industry.119 And for the diagnostic categories for which drugs are far and away the first-line form of treatment (such as for the “mood disorders,” “eating disorders,” “psychotic disorders,” and “anxiety disorders”) an average of 88 percent of all DSM-IV panel members had drug-company financial ties.
This trend has continued with the writers of the new edition, DSM-5 (due May 2013). Of the twenty-nine taskforce members writing the manual, a full twenty-one have received honoraria, consultancy fees, or funding from pharmaceutical companies, including the chair of the taskforce, Dr. David Kupfer, and the vice chair, Dr. Darrel Regier.120 As Spitzer said to me in an interview almost apologetically, “Today it is very difficult to find somebody or a large number of people who have not had some pharmaceutical support.”
So the question that brought me to Washington is one that should concern us all: Are these financial entanglements corroding the independence of the psychiatric profession itself?
2
The person I wanted to help me answer this question was Senator Chuck Grassley, a senior member of Congress who supports intensified regulation of the mental health industry. His story is compelling. He began life as a farmer in Iowa, never intending to reach high political office. But once his local reputation spread as a spokesperson for “the ordinary struggles of ordinary folks,” he was drawn into local politics, then into state politics, before securing a place in Congress. He has now been a senator for over thirty-two years and is still a man with a mission: the moral reform of corporate America.
His reputation in Washington for countering corruption is so solid that the US Justice Department now refers to him as the “federal government’s best weapon against fraud.” Little has escaped his attention: corrupt tax practices, lax regulation of government agencies, the financial irregularities of corporate elites, and, more pertinent for us, the misdemeanors of psychiatry.
I was excited to meet Grassley. His communications director, Jill Kozeny, welcomed me warmly and led me rather ceremoniously down a long corridor toward his office. Jill gave a gentle tap on the senator’s door before gently pushing it open. Senator Grassley was poised ready in the middle of the room—tall, lean, senatorial, commanding. He strode toward me confidently, and with a handshake like a quarterback’s boomed with a smile, “So you’re from England, huh? Well, come on in then, take a seat, we’ve got a bit of time.”
I was becoming accustomed to grand offices. Grassley’s didn’t disappoint. The seating area to the right was comprised of antique chairs and elegant Chesterfield sofas, all encircling a large, mahogany coffee table. To the left rested an intimidatingly large writing desk, flanked ceremoniously by flags—the Stars and Stripes on one side, the flag of Iowa on the other. Against the wall behind me were rows of dark, wood cabinets filled with books and federal files, and directly opposite the door warmly ticked a grandfather clock atop the soft, maroon carpet. The office seemed more like a museum exhibit than a place of work, and I struggled to appear nonchalant despite an incredible urge to take a picture.
It was clear that Senator Grassley and I would not be alone. The communications director and a senior assistant, who were busily arranging various folders and notebooks as we sat down, would join us. These assistants, as I would later discover, would be very much part of our meeting—fact-checking, jumping in with additional information, and sometimes qualifying what Grassley said.
What I wanted to know first was how Grassley became interested in the relationship between psychiatry and the pharmaceutical industry. So once a few preliminary pleasantries were past, I put the question directly to him.
“I was chairman of the finance committee here in Washington,” answered Grassley coolly, “and this committee pays for all of the Medicare and Medicaid medicines in the US. This gave us jurisdiction over the Food and Drug Administration [the FDA], which is the agency responsible for ensuring that prescription drugs are efficacious and safe for the public to use.”
Grassley’s relationship with the FDA was initially smooth, until one rainy afternoon a whistle-blower from the agency entered his office with a barrage of disturbing revelations. “We learned that the scientific and regulatory processes within the FDA weren’t working properly,” said Grassley with a growl. “They were being compromised by a lot of people at the FDA who had too close a relationship with the pharmaceutical companies. The FDA was approving drugs for public use which some in-house scientists knew were dangerous. And when these scientists tried to speak out, the FDA put enormous pressure on them to shut up.”
Just in case you have forgotten, we encountered the FDA back in chapter 4. Like its equivalent in Britain (the MHRA), it’s the organization that merely requires a company to show in just two clinical trials that their antidepressant is more effective than a placebo. If this can be shown, then no matter how many negative studies there have been, the drug will be approved for public use.
But this issue of “discarding the negatives” was not the problem Grassley was now referring to. He was, rather, alluding to a scandal concerning a drug called Vioxx made by the pharmaceutical giant Merck. The scandal unfolded in this way: A scientist at the FDA called David Graham decided to go public about how the agency had ignored warnings that Vioxx was killing people by causing heart attacks and strokes (as many as 140,000 heart attacks, according to Graham). Furthermore, even before Vioxx was sent to the FDA for approval, it was clear there were questions at Merck about the drug’s safety. Graham’s point was that not only should the FDA have never approved the drug for public use, but that Merck should never have even submitted the drug for approval. Once Grassley got wind of these problems, his suspicion of the dealings at the FDA was ignited—a suspicion that has in no way abated.
“Whenever I get the heads of the FDA in here,” said Grassley, leaning forward intently, “I ask them all the time whether things have been put right. Every one of them sits there and promises that things are going to be changed. But we never really know until there is another scandal.” Grassley then paused momentarily, as if recalling something important. “Actually, I don’t know if we’ve had any recent scandals or not.”
“We do!” supplied one of Grassley’s spritely assistants. “There was another group of FDA whistle-blowers that had come to see Senator Grassley. The FDA got wind of it, so they hacked into these scientists’ personal e-mail accounts to monitor the discussions they were having with Senator Grassley.”
“And that reminds me,” boomed Grassley, banging the chair with his fist, “we are going to get the FDA director in here to pursue that, right? Because they aren’t even answering our mail yet. So what have they got to cover up?”
These struggles with the FDA led Grassley to turn his attention more specifically to the doctors themselves, especially those who work as academic researchers within universities. This group is crucial to the pharmaceutical industry because they have the power and influence to alter the opinions and prescribing habits of the wider community of practitioners. When a university professor or leader in the field speaks up on behalf of a drug, other doctors listen. And this is why companies actively and aggressively recruit their services: doctors simply trust them more than they do company reps.
The companies themselves even have a term for these influential doctors: KOLs (Key Opinion Leaders). But given the potential conflicts of interest involved in being both a psychiatrist and a KOL, psychiatrists who work in universities are expected to report any income they receive from pharmaceutical companies for research, speaker’s fees, or work on advisory panels. Grassley was interested in whether this reporting system was working within the universities. Were doctors accurately reporting their industry income? He undertook an investigation to find out.
What Grassley first discovered was that when financial disclosures were being made, they were usually kept secret. As he put it in a speech delivered to the Senate floor in 2007: “If there is a doctor getting thousands of dollars from a drug company—payments that might be affecting his or her objectivity—the only people outside the pharmaceutical industry who will probably ever know about this are the people at that very university.”
A further and more serious problem he encountered was that the universities were terrible at keeping track of who was being paid what. “The reason why the universities weren’t checking things,” said Grassley to me heatedly, “was because the National Institute of Health wasn’t paying much attention to how the universities were conducting their affairs. This meant that the only people who knew whether the reported income was accurate or not were the actual doctors receiving the money.”
This problem first became apparent after Grassley sent a letter to the University of Cincinnati asking about how much money the drug companies had been paying to one of its psychiatrists, Dr. Melissa DelBello. Grassley had become interested in DelBello ever since her work on bipolar disorder in adolescents had been discussed in the New York Times. Her study, which was funded by pharmaceutical company AstraZeneca, showed that Seroquel (yes, Seroquel again) was particularly effective for treating bipolar disorder in children. This study, which helped put Seroquel on the map, led to DelBello being hired by the company to deliver promotional talks to other psychiatrists about the virtues of the drug. When Delbello was asked by a reporter at the New York Times how much she’d received for this promotional work, she replied curtly, “Trust me, I don’t make much.”
But Grassley wanted to know how much. So he contacted her university to find out. The university disclosed that a year after DelBello’s influential study was published, AstraZeneca paid her over $100,000 for lectures, consultancy fees, travel expenses, and service on advisory boards. In the year after that, she received a further $80,000 for the same services. In subsequent years (between 2005 and 2007) DelBello was also paid a further $238,000 by AstraZeneca. The problem was that for that same period she had only reported earnings of $100,000 to her university. As DelBello had not been reporting her industry income accurately, were other doctors doing the same? Grassley cast his net further to find out.
The next person Grassley caught came as a total surprise to him. His name was Professor Charles Nemeroff and he was chair of psychiatry at Emory University—one of the most prestigious psychiatry departments in the United States. Now, the thing about Nemeroff was that for many years he had been widely accorded almost rock-star status in American psychiatry, being referred to as the “Boss of Bosses” by a leading psychiatric journal due to his voluminous drug research and many charismatic public appearances. Behind the glamour, however, another story was waiting to be told—one that again would be written by Grassley.
In short, officials at Emory University had been aware for some time that Nemeroff was slippery when it came to declaring drug company income. In 2004, authors of a fourteen-page university report had asserted that Nemeroff had committed “serious” and “significant” violations of university policy when it came to stating his conflicts of interest (this seemed to have been linked to his receiving money from sitting on no less than twenty-six different pharmaceutical advisory boards). Rather than severely sanctioning Nemeroff, apparently the university gave him a gentle tap on the knuckles and let the matter slide.121
This would prove to be a mistake, because Nemeroff’s misdemeanors would simply continue. For example, Nemeroff later published an article in the very journal of which he was editor-in-chief. In this article he gave a glowing endorsement of a treatment device made by a company from which he was also receiving consultancy fees—fees he did not declare (something he put down to a “clerical error”). Then another scandal broke regarding a book he had co-written, which taught family doctors how to treat psychiatric disorders (largely with psychiatric drugs). While the preface disclosed that the authors had received an “unrestricted educational grant” from a major pharmaceutical company, it did not acknowledge the true extent of company involvement, which included the company paying a writing firm to develop the outline and text of the book while requiring the authors to send drafts to the pharmaceutical company for “sign-off” and for “final approval.” It was argued by many critics that, obviously, Nemeroff had been paid by the company to put his name to a book that largely promoted company products.
As these and a series of other alleged infringements continued, the university seemed none the wiser … not until Grassley’s investigation began to shed light on Nemeroff’s accounts. As the figures came in, Grassley discovered that between 2000 and 2007 Nemeroff had earned a staggering $2.8 million in personal income from drug companies, while only declaring income of $1.2 million to university officials. This included receiving from GlaxoSmithKline a full $960,000 of personal income between 2000 and 2006, while he’d only declared $35,000 to Emory. But what disturbed Grassley more was that at the same time as receiving money from GlaxoSmithKline, Nemeroff had also been given a grant worth a full $3.9 million (paid for by taxpayers) to study psychiatric drugs made by GlaxoSmithKline—the very same company from which he had received nearly $1 million in personal income.
“So I got the president of Emory in here,” said Grassley, pointing his finger angrily, “and I asked him, what are you going to do about this? He sits where you are and tells me that he’ll stop Nemeroff from getting any more federal grants for research while at Emory. But Nemeroff is a senior professor who is used to getting grants, so that’s no good for him. So what does Nemeroff do? He moves to another university [Miami], where he is made the new chair of psychiatry.” Grassley then turned to one of his assistants. “Now that reminds me, we’ve gotta find out whether he’s still getting federal grants down at Miami!”
“Sure,” said one of the assistants eagerly, “we’ll look into it.”
After the meeting I decided to look into it. Nemeroff had just been given another grant from the National Institute for Mental Health for a huge sum of around $2,000,000. His move to Miami had obviously paid off.
“There were other outstanding examples, too,” said Grassley crossly. The most prominent of these concerned another grand patriarch of the industry, the Chair of Psychiatry at Stanford University, Dr. Alan Schatzberg, who was also soon to become the president of the APA. What Grassley discovered was that Schatzberg controlled more than $4.8 million worth of stock in Corcept Therapeutics, a company he cofounded and that was testing a drug called mifepristone for psychotic depression. At the same time, Schatzberg was the principal investigator on a National Institute of Mental Health grant that included research on mifepristone. He was also found to be co-author of three papers about the drug.
When Stanford University was challenged about Schatzberg’s position, the university released an ill-advised statement declaring they saw nothing amiss with Schatzberg’s arrangement. This seemed an unreasonable claim to make since Schatzberg was the principal researcher for a drug from which his company stood to make millions if it were proven effective. Once the team at Stanford realized that Schatzberg’s position was indefensible, it released another statement a month later saying it was temporarily replacing Schatzberg as principal investigator to eliminate any “misunderstanding.”
As Grassley’s investigation unfolded, he exposed more and more psychiatrists for similar infringements. Some of the more prominent culprits included Joseph Biederman of Massachusetts General Hospital (colloquially know as the “King of Ritalin”), who was reported to have earned $1.6 million in consulting fees from drug companies between 2000 and 2007, most of which was not disclosed to Harvard University officials. There was also Dr. Frederick Goodwin, former director of the National Institute for Mental Health, no less. He was reported to have earned at least $1.3 million between 2000 and 2007 for marketing lectures to physicians on behalf of drug companies. He did not disclose this to relevant parties such as national media outlets where he’d been invited to speak publically about drugs. There was also Dr. Karen Wagner, professor at the University of Texas, who was reported to have failed to disclose more than $160,000 in payments from GlaxoSmithKline, disclosing only $18,000. Then there was Dr. Thomas Spencer, associate professor of psychiatry at Harvard Medical School. He failed to disclose fully his at least $1 million in earnings from drug companies between 2000 and 2007. Another culprit at Harvard Medical School was Dr. Timothy Wilens, who reported to Harvard he had earned several hundred thousand dollars in consulting fees when in fact he had earned at least $1.6 million.122
Grassley’s investigation slowly revealed that there was hardly a bank left in the country into which some senior psychiatrist hadn’t deposited unreported pharmaceutical cash. And as disturbing as this may be, what troubled Grassley more was that not one of the psychiatrists listed above had actually broken the law. This is because there is no current law (either in the United States or the UK) prohibiting psychiatrists or doctors from inaccurately reporting what money they receive. Of course, false reporting may be frowned upon within the professional community and may even be sanctioned by a particular university, just as Emory sanctioned Nemeroff at the prompting of Grassley. Even so, while no actual law was broken, the fact that the University of Miami still employed him as chair of psychiatry while knowing about his financial entanglements raises serious questions about the double-edged relationship some universities have with industry money.
For not only do individual psychiatrists benefit from company income, but so do many universities’ research centers that rely on the industry funds their faculty bring in. Nemeroff is a huge industry player, winning pharmaceutical grants with consummate ease, which makes him supremely attractive to psychiatry departments, especially because (as in the United States and the UK) there is almost no departmental funding available to underwrite research, while there are also very limited governmental or federal funds.
So Big Pharma fills an important funding gap, but it does so at a price. Pharmaceutical companies, after all, are businesses, not charities. So their bestowals can’t be classed as disinterested hand-outs; rather, they are investments from which companies expect a definite return. The question, of course, is: If universities begin to feel obliged to deliver on that investment, is there a danger they’ll lose some of their independence and start doing and saying things advantageous from the company’s standpoint?
3
To address this concern, let’s now consider the case of a professor of psychiatry called David Healy, who teaches at the University of Wales. For many years Healy had been investigating whether antidepressants can cause suicidal tendencies and violent behavior in patients. Such was the significance of his research, as well as his growing international reputation, that in 2000 he was formally offered the prestigious position of clinical director of the Mood and Anxiety Program at the University of Toronto.
Before he started his post, he was invited to the university to deliver a lecture on mental illness and addiction. During his lecture Healy argued that much research “demonstrating” the value of antidepressants was unconvincing, and that in rare cases these drugs can lead to suicide. The lecture seemed to go well, and he returned to Britain feeling satisfied with his performance. But two months later an e-mail from Toronto dropped into his inbox, retracting the university’s previous offer. The reason the university gave to Healy was that his work, as his lecture indicated, “was not compatible with the development goals and clinical resources of the department.” Healy was at first bemused by this change of mind, before wondering whether it had anything to do with his openly criticizing the pharmaceutical industry.
After Healy did some digging, his suspicions were compounded upon discovering that Eli Lilly, the company whose antidepressant he’d critiqued in his lecture, was a significant contributor to the University of Toronto. It turns out that it supported 52 percent of the budget for the Mood and Anxiety Disorder Clinic that Healy would have run, as well as having given $1.5 million to the clinic’s fundraising campaign. Healy also claimed he had discovered a precedent that the company could remove its financial support if anti-Prozac comments or publications were made by the clinic.123 Putting two and two together, Healy began to suspect that the university pulled its offer because it feared that he, by critiquing Eli Lilly, would threaten an important funding source.
And so, with the full backing of the Canadian Association of University Teachers, he sued the university. He argued that by retracting his job offer—perhaps because his views were potentially economically inconvenient—the university had essentially sent the message that certain viewpoints are undesirable. In short, Healy argued, they had violated the principle of academic freedom.124 Perhaps sensing the negative media attention this case would whip up, the case was finally settled out of court for an undisclosed fee (which Healy has claimed to have donated).
This particular story illustrates how company ties may compromise not only the integrity of institutions, but also the integrity of individuals working within those institutions. After all, the decision to retract Healy’s post was not made by an anonymous centralized computer system but by individuals who presumably had personal and institutional interests to protect. The fact that when push came to shove it appeared that Healy, rather than Eli Lilly, was sacrificed raises questions about whether accepting pharmaceutical money comes at the cost of retaining one’s full institutional, research, and clinical independence.
Whenever I put this question to a psychiatrist, the response I received invariably depended upon whether or not he or she was a recipient of industry money. Those who are recipients, perhaps unsurprisingly, regularly sidestep the idea that taking industry money is potentially corrupting, and they rather point out that the pharmaceutical industry is now virtually the only source of funding for research into new psychiatric drugs. How can a researcher therefore hope to study new drugs without having financial industry ties? Many also stress that engaging in promotional activities, such as speaking on behalf of company drugs, is a professional obligation: if a drug works, then psychiatrists have a responsibility to disseminate this knowledge to the wider medical community and beyond, and as such dissemination takes time, it’s only right that psychiatrists should be remunerated.
A similar argument is also used to justify accepting fees for company consultancy work: because psychiatrists are mental health experts, why should they deny companies their expertise? To deny their expertise surely means to debar the industry from a vital source of guidance and knowledge, they argue.
Most psychiatrists who’ve rejected company money often scoff at these arguments, indicating that they are often rationalizations physicians use for having put themselves in a compromised position. They argue that if all research into psychiatric drugs is pharmaceutically sponsored (and therefore often interfered with by company employees), then the funding system simply has to change. Furthermore, if psychiatrists feel the need to promote drugs or consult for companies, then let them do so as long as they either do the work for free, or let them donate that income to charity. Taking money, the critics argue, too easily leads to the subtle corrosion of professional independence, which in turn can lead to putting company interests above the interests of patients.
For instance, some psychiatrists now use pharmaceutical money to supplement their salaries—often by very generous amounts. These supplements can ease many financial burdens. But the danger here, of course, is that once you have become dependent on such annual payments you have to keep doing whatever you are doing to ensure these payments don’t dry up. Usually this means doing and saying things that are cost-effective from a company’s point of view, because companies will rarely continue to invest in doctors from whom they do not expect to profit. Critics therefore insist that to palm from the pharmaceutical purse is to enter a Mephistophelian pact—one that gradually and often unconsciously erodes the recipient’s capacity to think and act objectively.
Dr. Carol Bernstein, the previous president of the APA, referred to this matter when I interviewed her at New York University’s Medical School in 2011. When I raised with her Grassley’s investigations, her response was unequivocal: “If you’re getting money and benefits from doing something, there’s going to be tremendous psychological incentive to keep doing that thing, whatever it is, even if it’s not science … Brilliant scientists were in bed with the pharmaceutical industry, and I think that they just got corrupted because you get all this money and you get all these perks and you stop thinking objectively. The purpose of pharma, yes, it’s to do with research, but it’s an industry whose purpose is to make money. So they’re going to do whatever they can to make money.”
When I quote this statement to industry-paid psychiatrists, the responses I get are interesting. Many of them acknowledge the dangers, then reassure me that, unlike others, they’re on top of it. Others simply shrug as if to say “what else can we do—the industry is our primary sponsor.”
This position seemed to be close to that offered by Dr. Ian Anderson, the chairperson for the current NICE guidelines in the UK into how depression should be treated throughout the NHS. I interviewed Anderson because he had recently helped alter a clause in the NICE guidelines that I believe can allow pharmaceutical companies to claim that antidepressants have “statistically significant” benefits over placebos, even though the “significant” difference could be as low as a single point on the Hamilton scale. I was concerned that this alteration gave the green light for companies to continue to make inflated public claims about the benefits of antidepressants when in reality the benefits could be completely clinically insignificant.
Toward the end of the interview, I then said, “I must ask you, Dr. Anderson, have you ever received money from the pharmaceutical industry for consultancy, research grants, conferences, honoraria, etc.?”
“Yes, yes, I have,” Anderson replied.
“But you can see how it may appear to people,” I continued. “On one hand you are creating guidelines for how depression should be treated in the NHS, while at the same time you’ve received pharmaceutical money. Furthermore, you have now controversially removed a threshold that may allow companies to make inflated claims about the power of their drugs. You can see how easy it is to make an argument that there is a bit of a cozy relationship going on here.”
‘There is no perfect solution to individual corruption,” answered Anderson, “if I can put it as strongly as that, since we are all influenced by different things to different degrees. I think one of the problems is that because some of the cutting-edge developments in psychopharmacology are tied in with industry, there is a danger [by severing these ties] of throwing out the baby with the bath water.”
Anderson sits on the fence. But this position would be more acceptable if we knew for certain that industry money did not bias the judgment of its recipients. The problem is that we can’t be so certain. For example, there were two recent, separate investigations of what happened when many hospital doctors were given corporate all-expenses-paid trips to seminars at popular vacation sites. Although these doctors said the gifts would never influence them, the investigations revealed that from the period after they had received their invitations, they significantly increased prescribing the promoted drugs.125
In a further study in the New York Times, staff analyzed the prescribing habits of psychiatrists in Minnesota. They found that, on average, psychiatrists who received at least $4,500 from makers of newer-generation antipsychotic drugs appeared to write three times as many prescriptions to children for the drugs than psychiatrists who received less money or none.126
Research like this is still scant on the ground, and it only charts the effects on prescribing habits, not on doctors’ clinical values, beliefs, and research practices. Nonetheless, it does flag what many people intuitively sense to be the case: that it’s harder to retain your independence when you receive money from a company holding a vested interest in your taking a position profitable to them.
4
Given the Grassley investigations discussed above, US readers could be forgiven for thinking that dubious pharmaceutical entanglements are mainly an American problem, and that other countries, like Britain, have escaped the worst excesses of industry involvement. This was certainly what I believed until I started digging more deeply back in the UK. It wasn’t long before I realized that regarding transparency laws, Britain is still far behind the United States.
Recent legislation initiated by the Obama administration (called the Physician Payment Sunshine Act) will, as of 2013, oblige all drug and medical device supply manufacturers to track and report all payments made to physicians and teaching hospitals. This move toward greater transparency has been accorded a significant boost since full oversight for the act’s implementation has been given to Senator Grassley.
Also, the American Medical Student Association has now set up a system requesting all medical schools to report how many faculty members have acknowledged having these ties.127 Today you can find online which US universities are tightening their policies on drug ties, and find out how many faculty employees have these ties. These moves toward greater transparency are attempts to balance the need for companies to recruit the expertise of doctors with the public’s need to know whether a psychiatrist is saying something because it is the best medical advice or because she or he has a financial interest in saying it.
So in the United States there may be a glimmer of light on the horizon, but what about in places like the UK? In 2011, the Association of the British Pharmaceutical Industry’s code of practice was updated to include new requirements for companies to declare, as of 2013, payments to doctors for attending medical congresses. These changes are of course welcome. But you also have to read the small print. This code does not include the obligation of companies to disclose payments to doctors for research and development work, including the conduct of clinical trials. Nor does it include a requirement for companies to disclose funding given to doctors for research. Furthermore, the code only requires companies to disclose the total yearly amount paid to all of the doctor-consultants who have provided services.128 Most significant, it does not require companies to disclose the individual names of these consultants, nor do companies have to disclose the names of doctors who have received speakers’ fees or hospitality and sponsorship for attending meetings and conferences.129
In short, if a UK citizen wants to know how much pharmaceutical money his psychiatrist has received this year, short of asking for personal accounts (and good luck with that) he has little hope of ever finding out.
But what about British universities? Under the Freedom of Information Act (2000), I made requests to eight universities chosen at random to disclose whether their psychiatry departments or psychiatric faculty had received payments from the pharmaceutical industry. These universities included Oxford, Cambridge, Manchester, Liverpool, the Institute of Psychiatry (Kings London), University College London, Newcastle, and Edinburgh. So what emerged? Well, two universities declared they hadn’t gathered the figures, a third declared (it turns out wrongly) that their psychiatrists had received no money, and I am still awaiting the figure from another university, while the remaining four declared that members of their psychiatry faculty had received pharmaceutical payments. Here is a breakdown.
None of the above universities would disclose their psychiatrists’ private industry income for consultancy work, speakers’ fees, etc. And in many cases this was simply because the university did not request this information. As Liverpool University put it, psychiatrists “are not required to report individual payments to the University, so we don’t hold any information which could be provided in response to this part of the request.”130
But even if universities make a commitment to gathering this information, that is no guarantee that all employees will play ball. For example, one senior British psychiatry department declared to me that their faculty had reported no payments at all, even though there was a responsibility for faculty to do so. Yet after a mere five minutes of searching online, I discovered that at least three of its senior psychiatrists had declared receiving pharmaceutical money in their published research. After I wrote back to the university to point out this discrepancy, a week later another e-mail dropped into my inbox reaffirming curtly: “As we have stated, we are not aware of any academic staff receiving payments from pharmaceutical companies and this would include all academic staff both currently and previously employed by the university.” The phrase “we are not aware” makes it hard not to conclude that these psychiatrists, based at one of the most prestigious departments in the UK, had simply not reported their income to university officials.
The troubling truth is that neither universities nor pharmaceutical companies in the UK are obliged to declare under any kind of legislation the following critical information: the names of individual psychiatrists and what pharmaceutical money they receive for research funding, consultancy work, speakers’ fees, hospitality, educational activities, sponsorship, honoraria, and so on.
Without this vital information, we cannot check whether the eye-watering payments Grassley discovered in the United States are also being issued in the UK And this is particularly worrying since we know that payments are being made. What we don’t know is how much and to whom.
5
Once I left Senator Grassley’s office, I headed down the National Mall, that long covering of greenery stretching out from the US Capitol toward the Lincoln Memorial. As I walked close to the shade of the trees, I couldn’t shake one of Grassley’s final comments from my mind. “Good luck with how your work is received,” he had said with a hint of warning in his voice. It was almost as if he were saying don’t expect an easy ride. So as I continued on my way toward the memorial, I started recalling some of the responses I’d already received whenever people asked about this book.
Did their responses signal trouble ahead? Mostly the responses were genuinely encouraging. At other times, sure, they were non-committal. But then again, occasionally I did indeed receive reactions that verged on hostile. “Why are you taking on the community?” an older associate asked suspiciously. “Hasn’t psychiatry got its house in order since the problems of the 1970s?”
Another man at an academic conference seemed incredulous, telling me that critiquing psychiatry was “a risky business” and asking, “Have you read Freud’s Totem and Taboo?” (This question, if you don’t know the book, implied that my true motive for critiquing psychiatry could be an unconscious desire to take a pop at “authorities.”)
Then there was a gala dinner at my old university where a young cardiologist with black-rimmed glasses and a kindly voice asked me about my research. After giving him a few ins and outs, he said, half-jokingly but also tellingly, “Why, are you a Scientologist?”
Of course I understand these reactions. Medicine is a profession to which we all feel we owe enormous debt and in which we are oftentimes right to trust. So when one of its specialisms is challenged, it would be naïve to expect everyone to take it well. So mostly I just let the more provocative comments slip, treating them as data to be stored rather than as invitations for dispute. After all, I have never felt troubled by authority per se, but only with its abuse. Power itself is neither good nor bad. It is how it is used that matters.
What disturbs me, and I suppose what disturbs us all, is when the powerful, in the name of serving others, begin to use their power to serve themselves. This is what enrages us about political expense scandals, or free press abuses of privacy rights, or good-old-boys networks protecting their own. Call us idealistic or whatever appellation you like, but we are right to feel consternation when people start wielding the privilege of power self-interestedly.
As I continued my way toward the memorial, there was one final comment still on my mind—one that had stood out from all the rest. A psychiatrist I had interviewed early on in this project put it to me frankly: “Don’t you practice psychotherapy, so don’t you have competing interests? Any critique of psychiatry is surely a goal scored for psychotherapy.” This got me thinking. Psychotherapy and psychiatry, after all, do compete for limited resources, both in the private and public sector. So a book like this, which exposes the weakness of psychiatry, could be potentially seen as inadvertently serving the psychotherapeutic profession (leading to increased employment for people like me). And yet, as sensible as this argument may be, his comment still left me feeling somewhat uneasy.
To be clear, I am also a social anthropologist (a profession from which I earn my living), and as an anthropologist I have never taken an either/or position with respect to psychiatry and psychotherapy. I have been critical too of psychotherapy’s limitations and excesses—something my previous academic work makes clear.131 After all, my professional aim has never been to put the interests of a single professional group within the mental health industry first, but only ever the interests of patients. Furthermore, although I have worked as a psychotherapist in organizations like the NHS, I have never received any money for the clinical work I have undertaken. So far I have preferred only to work voluntarily.132
Once I reached the Lincoln Memorial, I stood for a moment pilgrim-like at the foot of an icon. Lincoln has always fascinated me ever since reading his letters as a teenager. He had always been conflicted by power—reluctant to assume it, watchful of those wielding it, and consummately observant of its potentially corroding effects. As I sat in a shady area on the memorial steps, looking back soberly toward the Capitol, one of Lincoln’s sayings came to mind. “Nearly all men can stand adversity,” he had written, “but if you want to test a man’s character, give him power.” This quotation now seemed so thoroughly apposite to what Grassley had just revealed only moments ago: a psychiatrist warrants criticism to the extent his or her character has failed the test of power. But I also knew that this general notion applies to institutions as well as to individuals—institutions that, for one reason or another, have similarly failed the test of power.
As to how this notion applies specifically to psychiatry is a matter I shall explore next.